A patient with pustular psoriasis developed jaundice, peripheral blood eosinophilia, and biochemical evidence of hepatocanalicular dysfunction four weeks after the initiation of etretinate therapy. A liver biopsy specimen showed bile duct damage, a periportal inflammatory infiltrate composed of neutrophils, eosinophils and lymphocytes, canalicular cholestasis, and focal hepatocyte necrosis. Clinical exclusion of other possible etiologic factors coupled with near resolution of the biochemical abnormalities within six weeks after complete discontinuation of the drug indicates that etretinate may induce an idiosyncratic hypersensitivity reaction. This is the first report to document etretinate associated bile duct injury.
Ultrasound is used after extracorporeal shock wave lithotripsy of gallbladder stones to assess fragmentation. In many patients with apparently successful fragmentation, the posttreatment studies show an intraluminal, echogenic focus within the gallbladder, with posterior acoustic shadowing characteristic of an intact stone. Cholesterol gallstones were fragmented in vitro by means of lithotripsy, and the sonographic appearance of the fragmented stones was followed up over time to study factors that might affect the process. After lithotripsy, fragments settled and produced an echogenic focus with posterior shadowing indistinguishable from the appearance of an intact stone. These experimental observations led to the development of a clinical maneuver to overcome the diagnostic pitfalls posed by the reaggregation of stone fragments in situ. This rollover maneuver helps distinguish between intact stones and fragments, and prevents both diagnostic errors in follow-up and unnecessary retreatment.
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